Provider Demographics
NPI:1114411824
Name:JACOBSON, RICHARD MICHAEL (CAODC 7794)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:MICHAEL
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:CAODC 7794
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 E HERMOSA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-3733
Mailing Address - Country:US
Mailing Address - Phone:805-867-8090
Mailing Address - Fax:
Practice Address - Street 1:401 W MORRISON AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-6124
Practice Address - Country:US
Practice Address - Phone:805-347-3338
Practice Address - Fax:866-729-9741
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2018-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7794101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)